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Its now been eight weeks and a day since I had my combined Latarjet Operation and Biceps Tenodesis on July 8, and some huge progress has been made since that day! I'm now working half-time since last week and will step it up to 75% of my normal working hours, starting next week. Its only going to be physically easy administrative tasks and not my normal work as a radiographer, until my Philippines & Micronesia trip in December.

The images below are of my right shoulder and I have pointed out some details in them before and after my combined Latarjet Operation and Biceps Tenodesis. The fracture itself in my Glenoid was hard to see even in full-screen, so I did mark it in red. These images are taken by my colleagues at S:t Görans Hospital in Stockholm, Sweden. The angle in which these images are taken, makes it possible to see into the shoulder joint itself. The fracture on the first image is at the lower front of the Glenoid (socket) of my right shoulder.

The image above is from May 9, before the surgery on my right shoulder. The fracture has been marked in red and includes a large portion of the lower front part of the Glenoid. In addition to the fracture, there were three pieces of fragments of the damaged Glenoid and one of them can be seen on this image, as pointed out by the arrow. These X-ray images show primarily bone anatomy, metal objects etc, not soft tissue.

Since this image is before the surgery, its the only one where the Coracoid process is seen, the tendon of the short head of the Biceps attaches to it, as does the Pectoralis minor muscle. During my Latarjet Operation the Coracoid process was sawed-off with the Biceps tendon and the Pectoralis minor muscle still attached to it, and relocated to the front of the Glenoid (see images below).

The image above is from June 9, the day after my Latarjet Operation and Biceps Tenodesis, and a lot of things have changed compared to the previous image. On this X-ray one can clearly see where the Coracoid process has been sawed-off, as it is used to add bone mass to the anterior of the damaged Glenoid, physically preventing the shoulder joint dislocating and damaging the Glenoid even more.

The Coracoid process has been relocated to the Glenoid and fixed with two screws and a small plate, which can be seen on each side of the screw heads as tiny hooks from this angle. With the short head of the Biceps tendon and the Pectoralis minor muscle still attached to it, the result is a slightly different working angle of the short head of the Biceps, and even more so for the Pectoralis minor muscle.

The image above is from July 27, seven weeks after my surgery. Only minor progress in bone healing can be seen compared to previous image, and bone healing is what makes the recovery after a Latarjet Operation so lengthy, in my case six months. And once healed properly, it should result in a strong, stable and functional shoulder joint, eventhough mobility might not be quite as before.

The large Hill-Sachs lesion can easily be spotted and is where the lower front part of the Glenoid, that got fractured, made this impression as I fell three times on the already dislocated shoulder, while descending the mountain in the original climbing accident in Ecuador in December 2013.

I have also pointed out the area where the short head of the Biceps tendon has been fixed with a modern screw that does not show on X-ray images. Normally that Biceps tendon is attached to the upper part of the Glenoid, but with a damaged tendon, also a Biceps Tenodesis was performed while having the Latarjet Operation.

Read the first Ad Astra post about my Latarjet Operation & Biceps Tenodesis here: //adastra.jeandar.net/#post422 (including links to posts of all my shoulder injuries leading up to the Latarjet operation and Biceps Tenodesis).

- Months of physiotherapy remains, but I'm progressing a bit every day!

My right shoulder problems started in Ecuador with my climbing accident on Cotacachi, 4,944 m, on 7 December 2013, being hit by falling rocks and suffering a traumatic right shoulder dislocation. On the five hour descent I fell three times on my dislocated shoulder, inflicting multiple injuries to it and permanent damages. Read more about it here: //adastra.jeandar.net/#post377.

In addition to that accident, I suffered another shoulder dislocation in the Hottentots Holland Nature Reserve in Western Cape, South Africa, on 16 December 2015, due to the damages already inflicted on the shoulder in Ecuador. Read more about it here: //adastra.jeandar.net/#post414. I also dislocated my right shoulder in Windhoek, Namibia, on 3 January 2016, but managed to relocate the humeral head back into the socket myself.

Above: My photo from S:t Görans Hospital in Stockholm, Sweden, on 9 June 2016, the day after my Latarjet Operation and Biceps Tenodesis.

These four shoulder dislocations had left the gleniod cavity of my right shoulder fractured and fragmented, and with damages to the labrum and the long head of the biceps tendon. Also, temporary damages to my axillary nerve have resulted in full atrophy in the terres minor muscle and partial atrophy in the deltoid muscles. The whole idea with my Latarjet Operation and Biceps Tenodesis is to stabilise and strengthen the shoulder as much as possible, preventing further dislocations while still having full shoulder mobility.

Latarjet Operation

Shoulder dislocations are common injuries, especially in young and active people. A Latarjet Operation can be done to prevent repeated dislocations. Once someone has dislocated their shoulder, repeated dislocations can become more and more common. Some people develop such severe instability in the ball and socket joint that dislocations can occur with simple activities or while sleeping.

The picture below: The coracoid is sawed off from its attachment to the scapula. The coracoid is then moved, with the short head of the biceps tendon still attached to it, a few centimeters to the front of the damaged glenoid. Once in position, the coracoid is fixed to the glenoid with screws.

A Typical damage to the shoulder joint starts as a torn ligament the first time the shoulder comes out of socket. This injury is called a Bankart tear, and is seen very commonly in patients who sustain an initial shoulder dislocation. During that initial dislocation, or with subsequent dislocations, additional damage to other structures can occur. Often cartilage or bone about the socket is damaged, and these injuries may be more difficult to repair.

The X-rays, CT-scan and MRI exams of my right shoulder showed a bony Bankart lesion. Bony Bankart lesions occur when some of the glenoid bone is broken off with the anterium labrum. This leads to loss of the normal bumper of the socket and also loss of bone, making the shoulder joint more unstable. Two bone fragments of 6 mm and 4 mm were also seen in the glenoid on these exams.

When bone damage occurs, the damage can either occur to the ball or the socket of the shoulder. Damage to the ball is called a Hill-Sachs lesion, and in my case it even engaged in some over-head movements, me risking easily further dislocations. Damage to the socket causes fractures and bone loss to the glenoid. When the glenoid is damaged, the socket may progressively get worn away. As this occurs, the chance of recurrent dislocation goes up. In fact, glenoid bone loss can get to the point where patients have a hard time keeping the shoulder in the socket at all.

The video above shows a Latarjet Operation.

The Latarjet Operation accomplishes two important tasks: First, it increases the amount of bone of the shoulder socket to restore bone that has been lost. Second, the muscles attached to the coracoid create a sling, supporting the shoulder in the front of the joint. The Latarjet is a very successful procedure at restoring stability to the shoulder joint.

The Latarjet Operation is not a minor surgical procedure, and rehab after surgery can be lengthy, at least 4-6 months. Mobility is restricted for the first few months while bone healing occurs. At that point, gradually the shoulder motion can be increased, followed by progressive strengthening.

Biceps Tenodesis

Biceps Tenodesis involves detaching the long head of the biceps from it's superior labrum in the shoulder and reattaching it to the humerus bone, just below the shoulder. Tenodesis is preferable for more active people and uses modern fixation screws. The repair is strong enough to move the arm early after surgery.

The video above: My Biceps Tenodesis was performed at the same time as my open Latarjet Operation and not with Arthroscopy as in the video. However, the result is the same.

There have been damages to my supraspinatus tendon since the first accident in Ecuador, this I knew. But by performing the Latarjet Operation, it became evident that also the long head of the biceps tendon was suffering from a SLAP 1-2 damage. Therefore I had an open Biceps Tenodesis, in conjunction with the Latarjet, preventing it from further damage and risking a future rupture of the long head of the biceps tendon. My combined Latarjet Operation and Biceps Tenodesis took almost three hours to complete.

I went to Hottentots Holland Nature Reserve on Wednesday, to zipline with Cape Canopy Tour at their awesome location. While getting myself ready to be connected onto the seventh cable, the old injuries to my right shoulder caused it to dislocate. I knew straight away what had happened and that this was the end of an enjoyable day.

Standing on the seventh platform with my dislocated shoulder, a fellow zipliner from Brazil tried to help me get my right humerus back inte its proper place, but without any success. I had to be assisted on the remaining cables, since its impossible to quit this zipline tour due to the vertical rock walls that the platforms are located at.

The doctor used the Cunningham Technique to relocate my humerus back into the socket, at the private Vergelegen Medi Clinic, in Somerset West, South Africa.

Shoulder luxation is a common complication of trauma or misuse, and is often anterior indicating movement of the humeral head anteriorly out of the glenoid fossa. The Cunningham Technique involves massaging the bicipital muscle in the mid humerus, with the patient's affected arm adducted, and the elbow flexed.

At the same time the patient is told to move the shoulder superiorly, and posteriorly to allow the humeral head to relocate back into the glenoid fossae. Patient is often given pain management prior to the procedure to allow tolerance of the procedure.

My photos above pictures me at the Vergelegen Medi Clinic, in Somerset West in the late afternoon of 16 December. I didn't need any pain management prior, during or after the shoulder relocation, and they did not spill time having X-rays taken before relocating my dislocated right shoulder, only after.

The YouTube video above shows the Cunningham Technique being performed.

There is not much I can do at the moment, except relaxing and resting my shoulder. All the scuba and freediving with blue, mako and sevengill sharks, and sea lions have been cancelled due to this shoulder injury.

- The sharks are still out there, just have to come back and say hello to them another day!

With a single source CT scanner, the X-ray
source/detector system has to obtain data projections of 180° to take a cardiac
image. With the Dual Source CT, each of the two source/ detector combinations
only needs to travel 90°, to acquire diagnostic images of the heart.

Patients with fast,
irregular heart rates no longer need beta-blockers. Unlike most other organs, the heart can be regarded as a moving target.
Just like in photography, fast shutter speeds are needed to capture a speeding
car free of motion blur. Considering the rapid motion of the heart at about
70-75 beats per minute when resting, a single source CT scanner, even a
64-slice CT scanner, is still too slow to visualize the heart without motion
artifacts. As a result, beta-blockers have been given to patients with
heartbeats greater than 60-65 bpm to slow down their heart rates. With the Dual
Source CT, sharp cardiac images can be acquired independent from the heart
rate. Therefore, patients with fast, irregular heart rates or arrhythmia
seeking CT exams no longer need beta-blockers.

My photo above pictures the four month old Siemens SOMATOM Definition Flash CT machine, found at the hospital in Mariehamn, Åland.

In
addition to its speed, the Dual Source CT offers the ability to better
characterize soft tissues. Because X-ray absorption is
energy-dependent, changing the energy level of the X-ray source results in a
material-specific change of attenuation. With two X-ray sources scanning at
different energy levels at the same time, the Dual Source CT scanner acquires
two data sets with different attenuation levels simultaneously. This is Dual Energy
CT scanning (read below).

(Beta-blockers are medications used to treat
several conditions, often by decreasing heart activity. They work by blocking
the release of the hormones adrenaline and noradrenaline in certain parts of
the body. Noradrenaline is a chemical released by
nerves when they are stimulated. The noradrenaline passes messages to other
parts of the body, such as muscles, blood vessels and heart).

Dual Energy

It has always been an aim to collect as much information as possible for
differentiation of tissues. Spiral dual energy scanning opens the door to a new
world of characterization, visualizing the chemical composition of material. The
idea of dual energy is not new to the CT community. Earlier approaches,
including two subsequent scans at different tube voltages or two subsequent scans
at the same position, failed to seamlessly align the imaged anatomy. This
limitation was overcome by permitting the use of two sources at two different
kV levels simultaneously. The result are two spiral data sets acquired in a
single scan providing diverse information, which allows you to differentiate,
characterize, isolate, and distinguish the imaged tissue and material.

The X-ray tube’s kilo voltage (kV) determines the average energy level of
the X-ray beam. Changing the kV setting results in an alteration of photon
energy and a corresponding attenuation modification of the materials scanned.
In other words, X-ray absorption is energy dependent; scanning an object
with 80 kV results in a different attenuation than with 140 kV. In addition,
this attenuation depends also on the type of tissue scanned. Iodine, for
instance, has its maximum attenuation at low energy, while its CT-value is only
about half in high-energy scans. The attenuation of bones, on the other hand,
changes much less when exposed to low-energy scans compared to high-energy
voltage examinations.

Spiral Dual Energy exploits this effect: Two X-ray sources running
simultaneously at different energies acquire two data sets showing different
attenuation levels. In the resulting images, the material-specific difference
in attenuation enables an easy classification of the elementary chemical
composition of the scanned tissue. In addition, a fused image is provided for
initial diagnosis. Changing the tube’s kilo voltage results in a material-specific
change of attenuation, resulting in clinical, economical, and technical
benefits.

A highly detailed CT scan of the heart can safely and quickly rule out the possibility of a heart attack among many patients who come to hospital emergency rooms (ER) with chest pain, according to the results of a study that was presented by researchers from the Perelman School of Medicine at the University of Pennsylvania at the American College of Cardiology's 61st Annual Scientific Session and published on March 26, 2012, in the New England Journal of Medicine. The multicenter randomized trial comparing Coronary Computed Tomography Angiography(CCTA) and traditional cardiac testing methods revealed that chest pain patients with negative CT scans can be discharged safely from the hospital within hours. These findings may offer a new strategy for relieving the emergency room crowding that plagues many of America's hospitals, and could help to trim millions of dollars off the costs of care for one of the leading causes of ER visits.

A 64-slice Philips CT machine is used for CCTA examinations at Hringbraut hospital in Reykjavik, Iceland.

Chest pain is the second most common reason people go the emergency room in the United States, accounting for as many as 8 million visits each year at a cost of several billion dollars. Just 5-15% of those patients are ultimately found to be suffering from heart attacks or other serious cardiac diseases, since issues from pneumonia to indigestion to anxiety can cause the same types of symptoms. But more than half of chest pain patients are admitted to the hospital for observation or traditional evaluation such as cardiac catheterization or a stress test.

ECG is commonly used to synchronise the CT machine with a CCTA examination, for better images and lower radiation doses.

The authors studied 1,370 patients at five medical centers who were classified as low-to-intermediate risk for heart attack, meaning they had no previously identified heart disease and did not have cardiac risk factors such as diabetes or high blood pressure. They randomized patients to one of two arms: those who received a CCTA scan and those who received conventional care strategies to rule out serious blockages of the arteries supplying the heart. Of 640 patients whose CCTA was negative, revealing no clinically important coronary artery blockages, none died or suffered a heart attack within 30 days. The investigators also found that patients in the CCTA arm were more than twice as likely to be discharged directly from the emergency department to their homes (50%) than those who underwent traditional care (23%). Patients in the CCTA arm also spent significantly less time in the hospital (a median of 18 hours), compared to those in the traditional care group (25 hours). Those with negative tests had an even greater difference in the length of their hospital stay (12 vs. 25 hours). Additionally, CCTA proved to be more effective at identifying patients with coronary artery disease compared to stress testing (9% of patients had a positive test vs. 3.5%).

Beta-blockers and nitroglycerin are frequently administered at CCTA examinations, stabilising and lowering the heart rate to 60 beats per minute or less.

“CT scanning has long been used in emergency departments to learn the cause of other symptoms like abdominal pain and shortness of breath. It's available in many hospitals around the clock, so now we can answer important questions about chest pain right away and send patients home much more quickly," said lead author Harold Litt, MD, PhD, chief of Cardiovascular Imaging in the department or radiology. "This test allows us to get a very good look at the coronary arteries in a noninvasive way, and for the large majority of people who are shown to not have a narrowing of the arteries, it's an excellent alternative to cardiac catheterization."

CCTA generates three-dimensional images of the heart and the blood vessels surrounding it. The tests, which are conducted like a standard CT scan, cost about $1,500 and allow patients who have a negative scan to be discharged from the hospital within hours, while costs for those admitted to the hospital for stress testing and monitoring typically total more than $4,000 for each patient.

In general, the farther away one gets from the capital of Lao PDR, Vientiane, the less one can expect in terms of healthcare. In some rural parts of the country, where villages are not accessible by road during the rainy season, one might not find any form of healthcare what so ever. These parts of the country are also where the level of education is at its lowest, and cash might not be found at all.

At the time of my visit to Lao PDR, the official figure of how many Computer Tomography machines (CT) were found in Lao PDR was four, of which one was out of commission. As most official figures, this might not be entirely true since an accurate nationwide record does not exist. There are no machines in Lao PDR for Magnetic resonance imaging (MRI), and medical ultrasonography is used throughout most parts of Lao PDR.

By the way, Hopital is not a misspelling, but simply how the French word Hôpital is spelled in Lao PDR.

Speaking of conventional radiography equipment, more than half of all machines I saw in Lao PDR, were out of commission due to lack of funds, spare parts, or the knowledge of how to repair them. However, the one found on my photo above, was in operation at Hopital Mahosot.

In Hopital Mahosot in Vientiane, which is the premier level of healthcare in Lao PDR, I saw a single slice CT in use, see my photo above. These machines are no longer in use in Sweden, and haven’t been so for a really time now. The more slices a CT machine can achieve, the faster the examination of the patient, and more useful images are obtained for diagnostic purposes.

The third photo pictures the latest CT found in Lao PDR, at the time of my visit on 12 January 2012. The CT used here, is a brand new 64-slice machine that was donated to the hospital from a European donor. Lao PDR is a communist state that lacks funds for basic levels of general healthcare throughout the country. If you got money and can pay the medical bills, you may get a diagnosis if you’re ill or injured. Treatment for the diagnosis on the other hand, is often not available in Lao PDR.

In the newly built wing of the Hopital Mahosot in Veintiane, one will not only find the brand new donated CT machine. The mammography machine pictured on my photo above, is also brand new and found in the same wing of the hospital as the new CT machine. Hardly any examinations of patients were conducted with this new mammography machine, since one has to pay out of pocket, and not many are covered by an insurance policy.

The last photo pictures me in the middle, my friend and fellow colleague, Emil, to the left of me, and basically the entire staff working at the radiography clinic at Hopital Mahosot in Lao PDR. To the right in this picture, one can see that they use developed film for CT-scans. 0.3 mm slices are merged into 10 mm slices on the radiographs, and who knows what pathology might be missed out by doing so. This procedure is performed mainly because they can afford only a few computers, screens and expensive digital equipment. The lack of funds is evident throughout the health system in Lao PDR.

- Only one more post from my Southeast Asian trip will be posted this month: Baiyoke Tower in Bangkok, Thailand.

In rural parts of the Khammouane Province in Lao PDR, a health centre will form the first level of the health system. The village of Sop On (see previous post here on Ad Astra) had a health centre, which really can’t provide any kind of medical assistance in any serious cases of illness or injury. Traditional birth attendants, who do not have any formal medical training, are frequently consulted and traditional “medicin” may be preferred by a patient due to lack of proper medication at the health centre or the high costs involved. In Lao PDR more than 75% of the population live on less than 2 US$ per day. That’s unheard of in Sweden.

On my first photo above, various death rates are pictured in the health centre of Sop On. A typical determinant of health is the under five death rate per 1000 births. This will tell how many children die before reaching the age of five years per 1000 live births. In Lao PDR, the average under five death rate is above 50. In Sweden this figure is 2.

The second photo shows the interior of an ambulance at the Nakai district hospital. It is virtually an unequipped van, with the only purpose of transporting a patient to the hospital. Not much of medical assistance to a patient may be carried out here, compared to high-income countries. It isn’t even certain that the dirt roads will take the ambulance all the way to the patient and back. The costs for the ambulance ride will most certainly be paid out of pocket by the patient, since only a few have a medical insurance policy in Lao PDR.

If you are hospitalizes in Lao PDR and have no insurance policy, this may ruin the economy of the entire family. The option is of course not to seek medical attention, and suffer from illnesses and injuries that may kill you in the end. In a scenario like this, the patient may turn towards traditional "medicine" and medicinemen, as a last hope for cure and better health.

Photo number three pictures me beside an old mobile conventional radiography machine. As most radiography equipment I saw in Lao PDR, this one is not working. Lack of knowledge, funds for maintenance, and technical support, are major issues leaving plenty of radiography machines out of commission. Old machines that may be donated from high-income countries are also likely to break down without proper maintenance.

All conventional radiography machines I saw in Lao PDR were not digitalized, meaning they had to develop the film in order to obtain a radiograph. In Sweden, every aspect of the health system is highly digitalized and have been so for a decade and a half, or more.

The use of a sonography machine at the provincial hospital in Thakek is displayed on my fourth photo above. This is where one will find the best medical equipment and health facilities in the Khammouane Province of Lao PDR. Nevertheless, the medical hygiene aspect is simply uncomparable between Lao PDR and Sweden.

My last photo pictures an operation of a 40 year old female, suffering from an inflammation in her uterus. During this operation, the uterus was removed and hopefully she made a hastily recovery afterwards. In the Khammouane Province of Lao PDR, this type of medical procedure is only performed at the provincial hospital in Thakek.

The Khammouane Province is located in the middle of Lao PDR and has a total area of approx 16,135 square kilometers. The total population of this province is about 330,000 and Thakhek is the provincial capital, and it borders to Thailand across the Mekong River in the west and Vietnam in the east. This province has a fertile land suitable for agriculture. Most of its population are farmers and comprising some minority groups of Phuan, Phoutai, Tahoy, Katang and Kri.

The Khammouane Province has nine districts, of which I visited Nakai and Gnommalath, housing each a district hospital. The difference in standards, equipment, economical situation, and even in medical practice, differs a lot between hospitals found on the district level from the larger and relatively better equipped provincial ones, like in Thakhek. The lowest level of the official Lao health system will be found in Community Health Centres in the rural areas, where “traditional medicin”, healers and Tradition Birth Attendants without any formal education, can be incorporated into the health system in order to make a difference.

It should be mentioned that Lao PDR is one of the poorest countries in Southeast Asia. The consequences of an injury or illness may be worse in a low-income country than in a high-income country, since the healthcare system in many low-income countries relies heavily on “out-of-pocket” financing, meaning that the person seeking medical attention pays the costs himself. This type of unsubsidised financing may be devastating for a family living on a low income and facing medical expenditures. Either one seeks medical attention and pay the relatively high costs, or do not seek costly healthcare and risk one’s health and income for the family.

An injury or illness could easily make a person an economical liability for the family in many low-income countries. Seeking medical attention in low-income countries may also make a person owe a debt for medical expenditures. The financial barrier that faces poor people may hinder medical access and continuation of treatment in many low-income countries. In a sense, this could also affect the country’s workforce, productivity and economical growth. In a high-income country taxation or insurance policies can subsidise medical expenditures.

During the Karolinska Institute’s Global Health Course in Lao PDR, I visited the district hospitals in Nakai and Gnommalath besides the Provincial hospital in Thakhek. Fieldwork in the village of Sop On was performed as a thorough review of families in the village and its Community Health Centre. The fieldwork I and two medical students performed in Sop On, included interviewing a family about their situation concerning: water & sanitation, food, shelter, healthcare and security. All photos are from that interview on 4 January 2012, picturing their living conditions.

On the first photo, I've pictured the fairly newly built house of the family I and two medical students interviewed. Sop On is a resettled village due to a newly built dam, and all the houses are better than in the old village, funded of course by the company building the dam.

The second photo shows the me to the left, the husband and his wife, and the interpreter in red, while interviewing them. Photo number three pictures the sleeping quarters of the house, the mosquito net that's used by night, is clearly seen here. Malaria and Dengue fever are easily prevented with mosquito net and mosquito repellents.

On the fourth photo, the living room is pictured. This family had a TV set and also a DVD-player, most probably funded by the company that built the dam! The house got a tin roof and was not wind proof, but it was still better than the old one. The sanitation facilities was also funded by the company that built the dam.

The last photo shows the kitchen of the household, that's hardly wind or water proof, and without all of the equipment and comfort found in a kitchen in a high-income country.

The solid theory part of the Karolinska Institute's Global Health Course, has provided us with knowledge of health determinants, and how they may vary between countries. The difference in health system and the socio-economical situation is evident throughout Lao PDR, compared to Sweden. Lao PDR is one of Southeast Asia's poorest countries.

The past week has seen plenty of fieldwork in the Khammouane province of Lao PDR. The city of Thakhek has been the base for visiting rural villages, where we interviewed families about their health situation and life in general. Local health centres, district hospitals and finally the province hospital in Thakhek was included in a full-packed itinerary, that also saw some leisurely visits to two caves. The inteviews resulted in five group presentations, where official representatives from both the Karolinska Institute and the healthcare system of Lao PDR were present.

The lack of funds, education and the health situation in the country are firmly linked to one and other, and are different in the districts and provinces of Lao.

This weekend, basically the whole group is in the city of Vang Vieng for some leasure and pleasure, and tomorrow the last leg of the course will begin in the capital city of Vientiane. Virtually all radiography equipment in the rural areas have not been in operation due to technical or mechanical errors. All in all, there are only four CT-machines in Lao PDR, of which three are in operation. No MRI's are found in the country, but sonography is performed even in the rural hospitals.

In the year 1800, health indicators as life expectancy at birth, fertility rate, under-five mortality rate and average income per person indicates that the human population faced more or less a similar level of health. The life expectancy for all countries, at this point in history, is found in the range 25 - 40 years. Only a few countries had industries, thus resulting in an increasing average income per person, and also giving a slow raise in public health in those countries.

Virtually all Western countries evolved faster due to the industrialisation in the 19th century, with a population growth, increasing income, and health, which has been ongoing until this very day. Only Japan joined the Western countries in the industrialisation at the end of the 19th century and through 20th century, and displayed a similar development in health.

The photo pictures me as a radiographer in Åland, Finland, in June-August 2011.

Asia’s development miracle and Africa’s development tragedy

Through trade, colonisation and military and economical dominance in parts of Asian and Africa, the gap between industrialised countries and African and Asian kept increasing, speaking of health.

After World War II ended in 1945, an increasing number of Asian countries gained independence from their colonial masters. This was the start of Asia’s economical development miracle through industrialisation, which has included an elevation in general health development on the continent. Some Asian countries are today reaching the highest standards in health, or closing the gap on it. A few countries in Asia and North Africa can also thank their oil for a very rapid general health development.

The sub Saharan countries on the other hand are still mainly agricultural, and have not been able to develop a similar economical growth and elevate public health as the Asian countries. High numbers of HIV victims in sub Saharan countries also contributes to Africa’s development tragedy. Sub Saharan countries display the lowest life expectancy figures and poorest healthcare systems in the world, along with Afghanistan.

The public health system in Lao People's Democrating Republic is predominant, although the number of private clinics is growing. No private hospitals exist, but there are private pharmacies and private clinics, mainly in urban areas. The state system is underutilized in the peripheral areas. Four administrative levels in the health system are found: central (Ministry, College of Health Technology and reference/specialized centers), provincial (provincial health offices, provincial and regional hospitals, and auxiliary nursing schools), district (district health offices and district hospitals), and village (health centers) levels.

The main expenditures are from the households and the government: 61% from households and 19.1% from the government. Hospitals in Lao PDR are highly dependent on user fees for recurrent expenditure, and there are four different social health protection systems in the country. Two of them focus on the formal sector for civil servants and private sector employees, and two cover the informal sector on a voluntary basis and the poor through equity funds, which are funded by donors and partially by the government. Donor spending is estimated to have made up 30% of total public sector health spending in 2007. Salaries account for 75.3 % of public expenditure on health.

Photo from Ersta Hospital in Stockholm, Sweden, December 2010.

Health system and health financing in Sweden

In Sweden, the healthcare system is organized on three levels: national, regional and local. The regional level, through the county councils together with central government, forms the basis of the healthcare system. The county councils plan the development and organization of healthcare according to the needs of their residents. Their planning responsibility also includes health services supplied by other providers, such as private practitioners and physicians in occupational medicine. The aim of primary care is to improve the general health of the population and to treat diseases and health problems that do not require hospitalization.

The Swedish healthcare system is primarily funded through taxation. Both county councils and municipalities have the right to levy proportional income taxes on their respective populations. In addition to taxation revenue, financing of healthcare services is supplemented by state grants and user charges. The social insurance system, managed by the Swedish Social Insurance Agency, provides financial security in case of sickness and disability. No basic or essential healthcare or drug package is defined within Swedish healthcare.

The relationship between physical activity and mental health has been widely investigated, and several hypotheses have been formulated about it. Physical exercise might represent a potential adjunctive treatment for neuropsychiatric disorders and cognitive impairment, during the aging process, helping delay the onset of neurodegenerative processes. Even though exercise itself might act as a stressor, it has been demonstrated that it reduces the harmful effects of other stressors when performed at moderate intensities.

Neurotransmitter release, neurotrophic factor and neurogenesis, and cerebral blood flow alteration are some of the concepts involved. The potential effects of exercise on the aging process and on mental health are demonstrated by some of the recent findings on animal and human research. The overwhelming evidence present in the literature today, suggests that exercise ensures successful brain functioning.

Numerous studies have indicated that individuals consuming a diet containing high amounts of fruits and vegetables, exhibit fewer age-related diseases such as Alzheimer’s disease. Research from laboratories has suggested that dietary supplementation with fruit or vegetable extracts high in antioxidants, decrease the enhanced vulnerability to oxidative stress that occurs in aging. These reductions are expressed as improvements in behavior.

Additional mechanisms involved in the beneficial effects of fruits and vegetables include enhancement of neuronalcommunication, via increases in neuronal signaling and decreases in stress signals, induced by oxidative and inflammatory stressors. Also, collaborative findings indicate that fruit or vegetable extracts high in antioxidants supplemented to humans with mild cognitive impairment, increased verbal memory performance. These results suggest that a greater intake of high-antioxidant foods, such as fruit or vegetable extracts high in antioxidants, may increase the “health span” and enhance cognitive and motor function in aging.

If training hard, taking a good multivitamin/mineral and a high-end protein supplement could prove to be a good idea. Staying hydrated with lots of clean water is as important as food. Focus on superior food products of all types, not the cheapest or most abundant brands. Our bodies can only rebuild with what is given to them to work with, so make it quality! Remember, what your body looks like in twenty, thirty, or fifty years is determined by what you feed it today.

Exercise

The second area to heed is exercise. Many may enjoy the weight room but ignore the treadmill, which is a huge mistake. Also, many running addicts detest the dumb bells, which also compromises their overall health. Neither is better than the other. We must pay attention to the heart and the muscular system for complete wellness.

Look at the big picture and how it relates to your current health and fitness routine and goals. For good physical benefits, you can do cardio as little as twice weekly, and the same goes for the weights. Make sure your training programme is balanced!

Avoiding drugs

The third aspect of your healthy triangle should be avoiding drugs and other chemicals that can negatively impact your body and mind. The single greatest factor is nicotine (tobacco). After nicotine the most commonly abused drug is alcohol. A drink or two isn't bad and may even benefit you, but know when to say when.

After nicotine and alcohol, recreationaldrugs are commonly abused. We don't even know the long term effects of some of these substances, so playing doctor and self administering carries unknown and potentially deadly risks. This includes anabolicsteroids, so be smart and stay natural!

Whether you are a competitive athlete or a newly joined gym addict, take time to truly prioritise your goals. Pay attention to the foods you eat and the methods you use to exercise, and avoid unnecessary risks.

- In a disordered mind, as in a disordered body, soundness of health is impossible.

There should be no doubt that ones physical performance, while exercising, depends much on nutrition planning and timing. If the right nutrients are available at the right time and in adequate amounts for a period of time, positive results can follow.

Energy and macronutrient needs must be met during times of high physical activity, to maintain body weight and physical performance. Especially carbohydrates and proteins are needed to replenish glycogen stores and provide adequate protein to build and repair tissue. Sufficient fat intake should provide the essential fatty acids and fat-soluble vitamins, as well as contribute energy for weight maintenance. Regardless of the fact that body weight and composition can affect exercise performance, these physical measures should not be a criterion for sports performance.

Food and fluid should be consumed in proper amounts before, during, and after exercise to help maintain blood glucose concentration during exercise, maximize exercise performance, and improve recovery time. One should be well hydrated before exercise and drink enough fluid during and after exercise to balance fluid losses. Sports beverages containing carbohydrates and electrolytes can be consumed before, during, and after exercise to help maintain blood glucose concentration, provide fuel for muscles, and decrease risk of dehydration.

If adequate energy to maintain body weight is consumed from a variety of foods, vitamin and mineral supplements are not needed. Those who restrict their energy intake, use severe weight-loss practices, eliminate one or more food groups from their diet, or consume unbalanced diets with low micronutrient density, may require supplements. It is recommended that nutritional supplements should be used with caution, and only after careful product evaluation for safety, efficacy, potency, and legality.

Nutrition planning and timing may appear complicated at first, but fact is it isn't! Smaller meals are recommended, five to seven of them throughout the day. They are prepared faster, and one could even prepare several of them for days to come. Smaller meals are also easier to bring along and fit into short breaks during work. If one adds the dimensions of a well designed workout programme, a high level of discipline and motivation, to nutrition planning and timing, every workout will take you a step closer to your goal.

My nutrition plan and timing is improving all the time and so are my physical achievements. The photos below picture me on 29 October 2011, since then I've gained another 0.4 kg lean muscle mass naturally. My training routine fully complies with the WADA2011ProhibitedList:http://www.iwf.net/doc/WADA_Prohibited_List_2011_EN.pdf

- I'm turning forty-two years old today and have never been stronger.

Setting and monitoring goals

● Set realistic weight and body composition goals by asking yourself: At what weight and body composition do you perform best? What is the maximum weight that you would find acceptable? What was the lowest weight you maintained without constant dieting? How did you obtain your exercise goals?

● Focus on your healthful habits such as stress management and making good food choices. Not on the scale, daily weigh-ins serve no purpose.

● Develop lifestyle changes to maintain a healthful weight. Not for the sport, for the coach, for your friends, for your parents, or to prove a point.

Suggestions for food intake

● Low energy intake will not sustain physical activity. Strategies such as substituting lower-fat foods for whole-fat foods, reducing intake of energy-dense snacks, and portion awareness can be useful.

● Fat intake should not be decreased below 15% of total energy intake, because some fat is essential for good health. A negative energy balance may result in reduced physical performance!

● Five to seven small meals daily, including fruits and vegetables to provide nutrients and fiber, is recommended. Emphasize on increased intake of whole grains and cereals, and legumes. Make sure only the best products are consumed - always.

● A variety of fluids, especially water, should be consumed throughout the day, including before, during, and after exercise. Dehydration as a means of reaching a body-weight goal is contraindicated.

Other weight management strategies

● Don’t skip meals and allow yourself to become overly hungry. Be prepared for situations when you might get hungry, keeping nutritious snacks available for those times. A protein drink and a banana or apple is a good combo.

● Don’t deprive yourself of your favorite foods or set unrealistic dietary rules or guidelines. Instead, dietary goals should be flexible and achievable. Remember that all foods can fit into a healthful lifestyle. Developing list of “good” and “bad” foods is discouraged.

● Let scientific facts help you identify your dietary weaknesses and plan strategies for dealing with them. Only proven science gives you the nutritional and physiological tools to progress into a higher performance level!

● Remember that you are making lifelong dietary changes to sustain a healthful weight and optimal nutritional status rather than going on a short-term diet.

Jean Dar

One worldOne lifeOne moment

I have a passion for travelling, having visited multiple countries on six continents for longer or shorter periods throughout the years. My interests include a wide array of areas, spanning from creativity to scientific matters and culinary delights to physiology and beyond.

I speak fluently English and Swedish, and at best I do fairly well in Spanish, and less well in French.